Learning From Experience

Improving Early Tracheal Extubation Success After Congenital Cardiac Surgery

Peter D. Winch, MD, MBA; Anna M. Staudt, MD; Roby Sebastian, MD; Marco Corridore, MD; Dmitry Tumin, PhD; Janet Simsic, MD; Mark Galantowicz, MD; Aymen Naguib, MD; Joseph D. Tobias, MD


Pediatr Crit Care Med. 2016;17(7):630-637. 

In This Article

Materials and Methods

As part of a quality improvement process, data were reviewed for all children less than 1 year old who underwent congenital cardiac or great vessel surgery between October 1, 2010, and October 24, 2013. The project was exempted from formal review by our institutional review board, which determined the project to consist of a quality improvement process. Retrospective data were collected on use of CPB, tracheal extubation in the OR versus tracheal extubation in the CTICU, age, weight, procedure, Special Tertiary Admissions Test (STAT) score, Risk Adjustment for Congenital Heart Surgery (RACHS) score, CPB time, and need for reintubation, in-hospital mortality and hospital length of stay (LOS) after surgery.

We have developed a standardized analgesic and anesthetic management strategy across our pediatric cardiac anesthesia group. Our approach regarding anesthetic technique, acute normovolemic hemodilution, heparin administration, crystalloid and blood product transfusion, and pH management on bypass have been previously published.[6] In short, for patients that are planned for an OR extubation following surgery, fentanyl is dosed at an initial goal of 15–20 μg/kg, administered prior to surgical incision. This is supplemented with a dexmedetomidine infusion started at the rate of (0.5 μg/kg/hr) which is started after anesthetic induction, continued throughout the case during CPB, and discontinued just after weaning from CPB. Anesthesia is maintained with isoflurane and rocuronium is used for neuromuscular blockade. Intravenous acetaminophen is administered 30 minutes prior to tracheal extubation as an adjunct to postoperative analgesia. Additional narcotics are administered once the respiratory rate is reestablished at the conclusion of the surgery. Patients that present to the OR intubated and those who have comorbidities or other criteria that exclude them from an early extubation pathway are given fentanyl at an initial dose of 20–25 μg/kg, and additional fentanyl and midazolam prior to transport from the OR to the CTICU.

Categorical variables were presented as counts and continuous variables were presented as medians with interquartile ranges. Patient characteristics were compared using chi-square tests for categorical variables and Mann-Whitney U tests for continuous variables across four groups defined by timing of extubation and necessity of reintubation. Group 1 patients had tracheal extubation in the OR and remained extubated, group 2 patients had tracheal extubation in the OR, but required reintubation either immediately or in the CTICU, group 3 patients underwent tracheal extubation in the CTICU and remained extubated, and group 4 patients underwent tracheal extubation in the CTICU, but required reintubation (Fig. 1). Descriptive statistics were further stratified by the use of CPB. Among patients requiring reintubation, time to reintubation was coded as within 4 hours of CTICU arrival, within 4–24 hours of CTICU arrival, or within greater than 24 hours of CTICU arrival; and compared by extubation timing (in the OR [group 2] vs in the CTICU [group 4]). Survival analysis with in-hospital mortality as the endpoint was performed separately for early (OR) and late (CTICU) extubations using Kaplan-Meier curves with log-rank tests. The time metric for survival analysis was days from extubation to discharge, with patients surviving less than1 day excluded from this analysis. All analyses were performed in Stata/MP 13.1 (StataCorp LP, College Station, TX), and p value less than 0.05 was considered statistically significant. To elaborate on the statistical analysis, the hospital records were further scrutinized to determine if any patient data, including physical examination, laboratory data or observational data from parents, nurses or physicians, predicted respiratory failure.

Figure 1.

Graphic representation of patient groups.